Acute Angle Closure Glaucoma

5 Jun

Definition

characterized by narrowing or closure of the anterior chamber angle

 

Anatomy/Physiology

The normal anterior chamber angle provides drainage for the aqueous humor, the fluid that fills the eyeball.

When this drainage pathway is narrowed or closed, inadequate drainage of the aqueous humor leads to elevated intraocular pressure and damage to the optic nerve.

Normal intraocular pressure is 8 to 21 mm Hg.

In acute episodes of closed angle glaucoma, pressures are often 30 mm Hg or higher.

 

Risk Factors

Family history of angle closure

Age older than 40 to 50 years

Female

Hyperopia (farsightedness)

Certain medications, particularly over-the-counter decongestants, motion sickness medications, adrenergic agents, antipsychotics, antidepressants, and anticholinergic agents

 

Clinical Presentation (Signs/Symptoms)

Decreased vision or halos around lights

Headache

Severe eye pain

Nausea and vomiting

Conjunctival redness

Corneal edema or cloudiness

A shallow anterior chamber

A mid-dilated pupil (4 to 6 mm) that reacts poorly to light

 

Management

Obtain emergent ophthalmology consultation for immediate evaluation and to discuss appropriate medical treatment

Place the patient supine

For patients with significant decline in vision (eg, with affected eye, patient cannot read text they would normally be able to, or cannot count fingers), provide immediate treatment to reduce IOP:

 • Give timolol 0.5 percent, 1 drop to the affected eye, wait one minute, then

 • Give apraclonidine 1 percent, 1 drop to the affected eye, wait one minute, then

 • Give pilocarpine 2 percent, 1 drop to the affected eye every 15 minutes for 2 total doses; wait one minute after first dose, then

 • Give prednisolone acetate 1 percent, 1 drop to the affected eye every 15 minutes for 4 total doses

 • Give acetazolamide 500 mg IV (may give by mouth if IV medication not available)

 • If IOP remains significantly elevated (≥40 mmHg) 30 minutes after giving this regimen and an ophthalmologist is not immediately available to assume care, give mannitol 1 to 2 g/kg IV

• For all patients, relieve associated symptoms with analgesics (eg, morphine, titrate to effect) and antiemetics (eg, ondansetron, initial dose 8 mg IV)

 

Submitted by K. Dabrowski.

 

Sources: Uptodate.com: angle-closure glaucoma; picture

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